Introduction to Environmental Health / Environmental Medicine

Kory Groetsch & Brendan Boyle

MDCH/ATSDR ServicesHealth EducationHuman Health Risk Assessment

Document that describes possible risks.Risk ≠ Health OutcomesTool:evaluate severity of the exposure and determine public health actions

Exposure InvestigationStudy of the population engaging in behaviors that result in exposuree.g. Blood or urine samples, monitoring devices

Health StudyAssess health outcomes level relative to measured chemical exposures

Overview

Overview of Environmental Medicine within Environmental HealthCase StudiesProfessional Human ResourcesWeb Resources (CME ) State and Local Examples of Environmental Exposures

Environment – Key Elements

The places a person inhabitsNon – occupational

Indoors and outdoorsSchools (children)Home and back yard Recreational areas

Occupational OEM @ MSU: Ken Rosenman, MD (http://oem.msu.edu//index.asp)Work environmentOverlaps with non-occupational

BehaviorsGardening, running, eating (fish, meat, etc.)

EH Definitions (3 examples)Freedom from illness or injury related to exposure to toxic agents and other environmental conditions that are potentially detrimental to human health. Public health that protects against the effects of environmental hazards that can adversely affect health or the ecological balances essential to human health and environmental quality. Environmental health comprises of those aspects of human health, including quality of life, that are determined by physical, chemical, biological, social, and psychosocialfactors in the environment. It also refers to the theory and practice of assessing, correcting, controlling, and preventing those factors in the environment that can potentially affect adversely the health of present and future generations.

Environmental MedicineWork of clinicians

Definition: Study of effects upon human beings of external physical, chemical, and biologicalfactors in the general environment.

Clinical EM: Evaluation, management, and study of detectable human disease or adverse health outcomes from exposure to external physical, chemical, and biologic factors in the general environment.

Disciplines - EM

toxicologyepidemiologypublic health and preventionindustrial hygienepopulation medicine research methods

Clinical Approach – EM

Characterizing ExposureChemicalSource

Link exposure to disease

Patients - EMConcern about a chemical exposure; no symptoms but worried about future effects.Symptomatic – suspect environmental causeSymptomatic – known chemical exposureSymptomatic – no idea that something in their environment is the cause

Characterize Exposure - EMConfirm that exposure occurred

Medical History

Environmental Exposure History (I PREPARE)

Laboratory TestingCardinal Exposure Information

Identify the hazardous substancesDose received

Degree of contaminationDuration Frequency

Pathway of Exposure

Routes of Exposure

INHALATION INGESTION

DERMAL CONTACT

Environmental Media

Soil - ingestion, dermal, inhalation

Water - ingestion, dermal, inhalation

Air - inhalation

Sediment – ingestion, dermal

Food (wild, local domestic, store purchased)

Sequence of Exposure to Disease

Exposure Effects

Source Pathway Exposure Internal Effective Dose

Altered Structure/Function

Early Molecular Cellular Effects

Clinical Diagnosed Disease

Reversible?Measurable?

TissueOrganOrgan System

SymptomsCause?Chemical?

Reentrainment

SOURCESTRANSPORT

DEPOSITION

FOODSUPPLY

RunoffErosion

Combustion

Industrial Processes

DirectDischarge

Sources and Pathways to Human Exposures

Susceptibility

Latency period

Link Exposure to Disease - EM

Complicating FactorsLatency periodMultiple chemical exposuresPharmacokinetics

Long duration in the bodyLack of unique disease presentationLack of science (minimal toxicological or epidemiological published literature)

Link Exposure to Disease - EMGood exposure information (chemical, dose, duration, frequency) exposure historyPossible effects/outcome information

Epidemiology literature human health outcomes Animal toxicology studies

Plausible effectHistopathology or biochemical indicators

Clinical case reportScientifically limited (lack controls, small sample, bias)Clinically valuable information (tests and treatments)

Local Clinical Experience

Link Exposure to DiseaseEvaluate medical history for alternative etiology and preexisting illnessEvaluation of Chemical Test Results

What do the test results represent?E.g. Time frame, tissue, relationship to exposure

Was quality assurance conducted? What values would one used to interpret the chemical test results?

Is the comparison value appropriate for clinical use?Human health based value?How was the health based number calculated?

Calculation assumptionIs it in the same tissue as the test result?

Timing and severity of health effects consistent with dose-responseRemoval from exposure ends clinical symptoms; re-exposure exacerbates symptoms

Diagnostic BenefitsEnd ongoing or prevent future exposures.

Assess future risk of disease from past exposures.

Help patient identify or eliminate possible causes.

MDCH/ATSDR – Can arrange a presentation by an OEM MD about making an Environmental Medicine Diagnosis.

Case Study 1 – EventDevine et al. 2002. EHP. V10 (10). P.1051-55 Grand Rounds Case Study

November 1996, a gas leak and “high” CO levels detected by gas company, in a kitchen of a restaurant. 45 yr old white female, who worked at the restaurant for 2 years, went to hospital 6 hr after detection of CO. Faulty furnace caused of CO, likely been producing CO for an extended period of time.Patient had been experiencing range of symptoms for about 1 year leading up to this discovery

Case Study 1 - Symptoms“flu-like”,balance problems unable to walk straight, bumping into things, several fallssevere headaches that persisted 24 hr/day, exhaustion, ear problems (right ear), “cloudy” sensation, impaired reading, writing and speaking tingling or numbness in both thighs, difficulty hearing, irritability, brittle teeth, pain in face.

Case Study 1:Medical History - HighlightsCollege educated, full scholarship, best subject was in languages, IQ >130

Patient denied birth trauma, hypertension, head injury, loss of consciousness, seizures, diabetes, thyroid, allergies, asthma, drug or alcohol use.

Patient was on vacation 5 days prior to the gas leak and discovery of elevated CO levels.

Peak symptoms were in Jan – April 1996.

Case Study 1:Medical EvaluationsFirst (May 1996)

Diagnosed with sinus infection – amoxicillinSymptoms became more severe, could not finish amoxicillin

Second - CO discovery (November 1996)6 hr after CO leak Carboxyhemoglobin not elevatedNo focal neurologic signs noted

Third - (February 26, 1998)Initial symptoms - 1 year prior to CO discoverySymptoms ended with CO discovery, except reading, writing, and speaking difficultiesNeurologist – MRI, finding were “normal

Case Study 1:Medical Evaluations

Fourth Medical Evaluation (April 15, 1998)Neuropsychological testing

Below expectationsDemanding tasks (attention, learning, memory retrieval, mood)Short-term memory

Sensitivity to interference when completing memory tasks

Results suggestive of subtle frontal/subcortical lobe dysfunction specifically in basal gangliaOwn clinical experience, typical of low level CO exposure without loss of consciousness.

Case Study 1:Medical Evaluations

Fifth Medical Evaluation (April 28, 1999)Neuropsychological testing

Similar below expectation resultsExecutive system dysfunction

Perseveration, pull to stimulus, poor development of strategies

Significant decrease in pyschomotor speedResults suggestive of subtle frontal/subcortical lobe dysfunction specifically in basal gangliaMRI Films

Conducted additional films with Fast Spin Echo MRI2 MRI experts (Neuroradiologist and Neuroscientist who does neuroimaging research from VA Boston Health Care systems) Blind to the medical historyMultiple small lesions bilaterally in the basal ganglia

Most severe in globus pallidus, less in the putamen

Case Study 1: LiteratureCO can cause all symptoms of the patient and those symptoms are non-specific.Acute symptoms, recovery, days or weeks later have neurologic/psychiatric symptoms

Progressive demyelination of white matterMarkers of Exposure

Carboxyhemoglobin (HbCO) in blood Half-life 4-5 hr in ambient fresh air45-80 min. at rest with 100% oxygenReflect [blood], not other [tissue]

CO in breathMRI

Lesions can be non-specificNeurologic Neuropyschological (lack destinctive pattern)

Case Study 1: Basis of Diagnosis

Environmental Exposure HistoryKnown CO leak in her work environment that likely exist for an extend period of timeDenied history of prior similar health issuesHigh IQ and highly educated

SymptomsHeadaches and “flu-like” symptoms

Medical ExaminationLesions in the basal gangliaQuantified memory difficultiesExecutive system dysfuntion

Confirmed finding in scientific literature, case study literature, and local clinical experience

Case Study 2: Case History PCC-Detroit, Consult of the Week, V. 1, No. 7 1/14/05

2 year old boy taken to Primary Care PhysicianDiagnosed with viral upper respiratory infection and possible anemia (slightly pale)PCP ordered blood lead test and CBCBlood lead = 57 mcg/dl (CV: <10 mcg/dl)Hemoglobin = 9.6 g/dl (Normal: 11-13 g/dl)PCP called parents- child taken to emergency

Case Study 2: ED Physical Exam, Labs, X-rays

Physical exam: Normal except for paleness of the conjunctiva and delayed speech.Lab: Repeat Pb = 64 mcg/dlX-ray:

paint chips in large and small intestine Abnormal bone remodeling and increased Ca deposits at several of the metaphyses.

Case Study 2: Literature Symptoms are not unique

Abdominal PainConstipation/DiarrheaDevelopmental DelaysAlterations in Mood

Health EffectsAnemiaDamage hemoglobin formationKidney diseaseNerve damageDevelopmental Delays

16

10 µg/dL

20 µg/dL

40 µg/dL

50 µg/dL

100 µg/dLand over

Slight loss in IQ; hearing and growth problemsModerate loss in IQ; hyperactivity; poor attention span; difficulty learning; language and speech problems; slower reflexesPoor bone and muscle development; clumsiness; lack of coordination; early anemia; decreased red blood cells; tiredness; drowsinessStomach aches and cramps; anemia; destruction of red blood cells; brain damageSwelling of brain; seizures; coma; death

Case Study 2: Child Reactions to Lead

Blood Lead Level Possible Health Effects

Case Study 2: DiagnosisPica child who ingested lead based paint chips (x-ray of chips and elevated blood test)Abnormal bone growth was attributable to the Pb exposureAnemia was most likely due to low Fe levels (Pb usually needs to exceed 100 mcg/dl to cause anemia)Delayed speech was not address in the diagnosis

Case Study 2: PCC treatment of lead poisoning of in asymptomatic children

Admit for BAL (injections) and CaNaEDTA (intravenous infusion)

> 70

Admit for inpatient chelation with meso 2,3 dimercaptosuccinic acid (DMSA) (oral) and CaNaEDTA(intravenous infusion)

40 – 69

retest lead level in 2 – 4 months, identify and abate source, education, nutrition counseling, medical evaluation by PCP

20 – 39

retest in 2 months, education, home inspection 15 –19

retest in 2-3 months, education 10 –14

Treatment[Pb] (mcg/dl)

Case Study 2. Treatment

Clear intestine glycol-electrolyte solutions (Golytely) via nasal gastric tube (NGT) with repeated abdominal films every 8 – 12 hours.

Chelation DMSA (oral) CaNaEDTA (intravenous infusion)

Case Study 2: Follow-up with Parents

Does the child exhibit pica behavior?How old is the home the child lives in?Does the child go to other homes for care? How old?Do other young children come to you home? Might they be eating paint chips?Please describe your child’s diet

Fatty foods cause paint chips to stay longer in the GI trackDiets low in Fe, Zn, Ca allows more Pb absorption.

Groups of Chemicals

Pesticideshome, farms, work, indoors and outdoors

Heavy Metals / Elemental Volatile Organic Chemicals

Short-chain organics Indoor Air Concerns (construction materials, glues, cleaning products)

Semi-Volatile Organic ChemicalsLong-chain organics

Regular Issues at MDCH – DEOE

Arsenic AsbestosAsthma – Environmental TriggersCancer ClustersChemical Terrorism PreparednessClandestine Lab Indoor Air

mold, sewer gases, CO, natural gas leaks Elemental mercury spillsLeadMiscellaneous chemical exposure Persistent Chemicals (dioxins, PCBs, chlordane, PBB, DDT, methylmercury)

Fish Consumption Advisory PesticidesSite-specific hazardous waste sites

Regional Exposure PathwaysFrequent Fish Consumption local waters

Pine, Tittabawassee, Saginaw River and Bay – resident species and benthic dwellersInland lakes – top predator fish

Wild Game Consumption from Tittabawassee R. flood plain (turkey meat and deer liver)Childhood lead exposure (homes older 1978)Carbon monoxide exposure

Gas generators, oil lamps, faulty furnaces

Elemental mercury spills

Regional ATSDR Site WorkTittabawasse River ContaminationCity of Midland ContaminationSaginaw River ContaminationVelsicol Chemical Plant Site (St. Louis, Mi)

Overview of Velsicol PlantNIOSH documented exposures and effects 1977 Source of state-wide PBB food contaminationChlorinated chemical production (e.g. DDT)Do not eat fish from Pine River between Alma and MidlandPreviously, wild game advisories along Pine River (end 1995)Recent discoveries of past plant-site clean-up (Late 1990s to present)

Leaking of DNAPL into Pine River (DDT)Highly elevated shallow ground water contamination off-site (not used for drinking water)p-CBSA in the drinking water wells of the City of St. LouisOff-site soil contamination of multiple chemicals above background, some samples exceed residential protection criteriaSoil gas issues (VOCs)

On-going investigations and clean-up both on and off the plant siteActive locally-run Community Advisory Group and Technical Advisory Group that stay on top of the issues and conduct continuing education to the public.

Human ResourcesAssociation of Occupational and Environmental Clinics (AOEC) (www.aoec.org)

Lansing, East Lansing, Detroit, Royal Oak Pediatric Environmental Health Specialty Units (PEHSUs) (www.aoec.org)

ChicagoPoison Control Center (www.mitoxic.org/pcc/)

Health Care Professional ResoucesCollege of Medical ToxicologistsToxicology and Response Section of MDCH

Web ResourcesHazardous Substance Data Bank (http://toxnet.nlm.nih.gov/cgi-bin/sis/search)Environmental Health Perspectives (http://www.ehponline.org/)National Agricultural Pest Information System (NAPIS) (http://ppis.ceris.purdue.edu/htbin/epachem.com)ATSDR (http://www.atsdr.cdc.gov/)

Case Studies in Environmental MedicineToxFAQsToxicological ProfilesMedical Management GuidelinesToxGuides

MDCH-DEOE (www.michigan.gov/mdch-toxic)MDCH Fact Sheet Matrix (www.michigan.gov/documents/fact_sheet_matrix_12-21-05 148400 7.xls)

Case Studies in Environmental Medicine

ArsenicAsbestosBenzeneChromiumLeadNitrate/NitritePolychlorinated Biphenyls (PCBs)Environmental Triggers of AsthmaTaking an Exposure History

Radiation Exposure from Iodine 131RadonStoddard SolventTolueneTrichloroethyleneDisease Clusters: An overviewPediatric Environmental Health

Continuing Education CreditsContinuing Medical Education (CME)The Centers for Disease Control and Prevention (CDC) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. CDC designates thiseducational activity for a maximum of 2.0 hours in category 1 credit toward the American Medical Association (AMA) Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity.

Continuing Nursing Education (CNE)This activity for 2.3 contact hours is provided by CDC, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation.

Continuing Education Units (CEU)Continuing Health Education Specialist (CHES)

EXTRA SLIDES NOT USED

Focal Neurological SignsFocal neurological signs help discriminate which part of the nervous system is affected by a lesion.Frontal lobe signs may include:

Mental disturbance, e.g. dementia, apathy, inappropriate emotionEpilepsyGrasp reflex, pout and snout reflexes Unilateral anosmia (Loss of the sense of smell. Also called olfactory anesthesia.)

Parietal lobe signs may include:sensory disturbance, agraphia (A disorder marked by loss of the ability to write.), acalculia (A form of aphasia characterized by the inability to perform mathematical calculations.

Temporal lobe signs may include:loss of long and short term memory

Factors that Result in Illness

Genetics, Current Health, Life Style, Environmental Exposures

Non-Occupational Sources Occupational Sources

OEM @ MSU: Ken Rosenman, MDhttp://oem.msu.edu//index.aspPhysical Chemical Biological

Infectious Disease

virus, bacterium, parasiteElemental

Organic

Environmental Health / Medicine

Heat